High-risk human papillomavirus distribution according to human immunodeficiency virus status among women with cervical cancer in Abidjan, Côte d'Ivoire, 2018 to 2020.

As human papillomavirus (HPV) immunisation and HPV-based cervical cancer (CC) screening programmes expand across sub-Saharan Africa, we investigated the potential impact of human immunodeficiency virus (HIV) status on high-risk (HR)-HPV distribution among women with CC in Côte d'Ivoire. From July 2018 to June 2020, paraffin-embedded CC specimens diagnosed in Abidjan, Côte d'Ivoire were systematically collected and tested for HR-HPV DNA. Type-specific HR-HPV prevalence was compared according to HIV status. Of the 170 CC specimens analysed (median age 52 years, interquartile range: [43.0-60.0]), 43 (25.3%) were from women living with HIV (WLHIV) with a median CD4 count of 526 [373-833] cells/mm3 and 86% were on antiretroviral therapy (ART). The overall HR-HPV prevalence was 89.4% [95% CI: 84.7-94.1]. All were single HR-HPV infections with no differences according to HIV status (P = .8). Among HR-HPV-positive CC specimens, the most prevalent HR-HPV types were HPV16 (57.2%), HPV18 (19.7%), HPV45 (8.6%) and HPV35 (4.6%), with no significant differences according to HIV status. Altogether, infection with HPV16/18 accounted for 71.1% [95% CI: 55.9-86.2] of CC cases in WLHIV vs 78.9% [95% CI: 71.3-86.5] in women without HIV (P = .3). The study confirms the major role of HPV16/18 in CC in Côte d'Ivoire and should support a regional scale-up of HPV16/18 vaccination programmes regardless of HIV status. However, vaccines targeting additional HR-HPV types, including HPV45 and HPV35, could further decrease future CC incidence in Côte d'Ivoire, both for WLHIV and women without HIV.

Changing attitudes towards HIV testing and treatment among three generations of men in Cameroon: a qualitative analysis using the Fogg Behavior Model.

INTRODUCTION: Men are less likely than women to test for HIV and promptly initiate antiretroviral treatment, resulting in advanced HIV disease and increased mortality rates among them. METHODS: In-depth interviews were conducted with men and leaders in the west and central regions of Cameroon. Men were recruited from existing community groups and stratified by age: 21-30 years, 31-40 years, and 41 years and older. Community leaders were recommended by the community dialogue structure chairman. Interviews were conducted using a semi-structured guide in English or French, depending on the participant's preference. Transcripts were coded in the MAXQDA v.12 software and analyzed using thematic analysis and by age group. The Fogg Behavior Model was used to gain a deeper understanding of the different perceptions across all age groups. RESULTS: Younger men (21-30 years) were generally more accepting of HIV testing, as it had become normative behavior. Although financial barriers could limit access, free testing was mentioned as a prompt to initiate HIV testing. The middle age men (31-40 years) had the most concerns about HIV testing interrupting their work day and recommended increasing testing locations and hours. The older men (41 + years) were the least motivated to get tested, citing worries about the impact on their social standing within the community. All age groups reported being motivated to begin treatment if they were found to be HIV-positive. Participants also provided insights regarding community HIV testing and treatment messaging. Younger and older men preferred to hear directly from qualified health professionals, but younger men noted that social media, radio, and TV could be utilized. Middle age men also identified TV and radio as effective mediums, if door-to-door messaging was not an option. CONCLUSIONS: The study highlights important considerations when planning future information-sharing activities for HIV testing and treatment. Since lived experiences differ across generations and societal roles continue to change, not only should the content of messages differ among the generations, but the means of communication must also be considered to ensure the messages are conveyed through a trusted source.

Chronic viral hepatitis, HIV infection and Non-Hodgkin lymphomas in West Africa, a case-control study.

Non-Hodgkin lymphomas (NHL) are underestimated causes of cancer in West Africa where chronic viral hepatitis and HIV are endemic. While the association with HIV infection has already been characterized, limited information is available on the association between chronic viral hepatitis and NHL in sub-Saharan Africa. A case-control study was conducted in referral hospitals of Abidjan (Cote d'Ivoire) and Dakar (Senegal). Cases of NHL were matched with controls on age, gender and participating site. The diagnosis of NHL relied on local pathological examination completed with immunohistochemistry. HIV, HBV and HCV serology tests were systematically performed. A conditional logistic regression model estimated the associations by the Odds Ratio (OR) with their 95% confidence interval (CI). A total of 117 NHL cases (Abidjan n = 97, Dakar n = 20) and their 234 matched controls were enrolled. Cases were predominantly men (68.4%) and had a median age of 50 years (IQR 37-57). While Diffuse Large B-cell lymphoma were the most reported morphological type (n = 35) among mature B-cell NHL, the proportion mature T-cell NHL (30%) was high. The prevalence figures of HBV, HCV and HIV infection were 12.8%, 7.7% and 14.5%, respectively among cases of NHL. In multivariate analysis, HBV, HCV and HIV were independently associated with NHL with OR of 2.23 (CI 1.05-4.75), 4.82 (CI 1.52-15.29) and 3.32 (CI 1.54-7.16), respectively. Chronic viral hepatitis B and C were significantly associated with NHL in West Africa. Timely preventive measures against HBV infection and access to curative anti-HCV treatment might prevent a significant number of NHL.

Human papilloma viruses infection among adolescent females perinatally infected with HIV in Côte d'Ivoire.

BACKGROUND: Cervical cancer prevention strategies recommend human papilloma virus (HPV) vaccination for female adolescents prior to their sexual debut. While HIV is a major risk factor for HPV infection in women of childbearing age, its prevalence among HIV-infected adolescent female is mostly unknown. This study aimed to describe the HPV prevalence and correlates among perinatally HIV-infected adolescent females prior to HPV immunisation. METHODS: A cross-sectional survey was conducted from January to June 2016, in the four major paediatric HIV clinics of Abidjan, Côte d'Ivoire. All HIV-infected females aged 11-16 years were approached to participate in the study. A questionnaire assessing sexual behaviours and genital hygiene practices was administered to participants completed with a systematic vaginal swab collection. HPV genotyping was performed using the Anyplex II HPV28 Detection (Seegene). A logistic regression analysis was performed to identify factors associated with the presence of HPV infection. HPV immunisation was proposed free of charge to all participants. RESULTS: A total of 250 participants were included, with a median age of 13 years (IQR 11-14). Among them, 237 (94.8%) were on antiretroviral treatment with a median CD4 count of 660 (IQR 439-914) cells/mm3. The overall prevalence of at least one HPV was 3.6% (95% CI 1.6 to 6.7) and the prevalence of at least one carcinogenic HPV was 2.8% (95% CI 0.7 to 4.8). Vaginal cleansing was reported by 75 (30%) of participants, with a median age at initiation of 12 years (IQR 10-13). Sexual activity was self-reported by 12 (4.8%) participants with a median age at sexual debut of 11 years (IQR 10-14). HPV infection was associated with vaginal cleansing (adjusted OR=7.0 (95% CI 1.4 to 31.6)). CONCLUSION: The reported low prevalence of carcinogenic HPV infections supports the appropriateness of HPV immunisation in this population. The reported association between cleansing practices and HPV infection deserves further prospective longitudinal studies.

Barriers and facilitators in cervical cancer screening uptake in Abidjan, Côte d'Ivoire in 2018: a cross-sectional study.

BACKGROUNDS: Cervical cancer (CC) incidence remains unacceptably high in Côte d'Ivoire. In an effort to prevent this malignant condition, a national CC screening program has been scaled up in the country. This study aimed at assessing CC screening uptake and its associated factors in Abidjan in 2018. METHODS: A cross-sectional survey was conducted from July to September 2018 in the main healthcare facilities of three randomly selected out of the eight health districts of Abidjan. During the study period, a standardized questionnaire was administrated by research assistants to all women aged 25 to 55 years old, attending the three participating facilities. Demographics, knowledge on CC, personal history of CC screening and reasons for not attending CC screening were collected. A logistic regression model was computed to document factors associated with reported CC screening uptake. RESULTS: A total of 1158 women with a median age of 32 years (IQR [27-36]), including 364 (31.4%) with no formal education were included. Of those participants, 786 (67.9%) had ever heard about CC. CC screening uptake at least once was reported by 7.5% [95% CI: 6.0-9.0] participants. In multivariable analysis, being ≥45 years (aOR: 6.2 [2.3-17.2]), having a university level (aOR: 2.8 [1.2-6.6]) (versus non formal education) and access to mass campaign information (aOR: 18.2 [8.5-39.1]) were associated with a reported CC screening uptake. The main reported barriers to CC screening were unawareness towards CC screening (75.5%), negligence (20.5%), fear of CC detection (3.9%) and fear of additional costs (3.3%). CONCLUSION: CC screening uptake remains low despite current initiatives to support awareness and prevention in Abidjan. Awareness campaigns need to be massively increased with the adjunction of tailored messages based on the level of women's education to enhance the CC screening coverage and reach the WHO goal of CC elimination by 2030.

Integrating pediatric TB services into child healthcare services in Africa: study protocol for the INPUT cluster-randomized stepped wedge trial.

BACKGROUND: Tuberculosis is among the top-10 causes of mortality in children with more than 1 million children suffering from TB disease annually worldwide. The main challenge in young children is the difficulty in establishing an accurate diagnosis of active TB. The INPUT study is a stepped-wedge cluster-randomized intervention study aiming to assess the effectiveness of integrating TB services into child healthcare services on TB diagnosis capacities in children under 5 years of age. METHODS: Two strategies will be compared: i) The standard of care, offering pediatric TB services based on national standard of care; ii) The intervention, with pediatric TB services integrated into child healthcare services: it consists of a package of training, supportive supervision, job aids, and logistical support to the integration of TB screening and diagnosis activities into pediatric services. The design is a cluster-randomized stepped-wedge of 12 study clusters in Cameroon and Kenya. The sites start enrolling participants under standard-of-care and will transition to the intervention at randomly assigned time points. We enroll children aged less than 5 years with a presumptive diagnosis of TB after obtaining caregiver written informed consent. The participants are followed through TB diagnosis and treatment, with clinical information prospectively abstracted from their medical records. The primary outcome is the proportion of TB cases diagnosed among children < 5 years old attending the child healthcare services. Secondary outcomes include: number of children screened for presumptive active TB; diagnosed; initiated on TB treatment; and completing treatment. We will also assess the cost-effectiveness of the intervention, its acceptability among health care providers and users, and fidelity of implementation. DISCUSSION: Study enrolments started in May 2019, enrolments will be completed in October 2020 and follow up will be completed by June 2021. The study findings will be disseminated to national, regional and international audiences and will inform innovative approaches to integration of TB screening, diagnosis, and treatment initiation into child health care services. TRIAL RESISTRATION: NCT03862261, initial release 12 February 2019.

Etiology of hepatocellular carcinoma in West Africa, a case-control study.

Hepatocellular carcinoma (HCC) is a leading cause of cancer in West Africa where HBV infection is endemic. However, limited information is available on other risk factors such as alcohol use, HCV and HIV infection. A case-control study was conducted in referral hospitals of Abidjan (Cote d'Ivoire), Bamako (Mali) and Lome (Togo). Cases were matched with controls on age, gender and participating site. The diagnosis of HCC relied on the combination of one or more space-occupying lesions suggestive of an HCC on a standardized abdominal ultrasound and an α-fetoprotein level ≥400 ng/ml. HIV, HBV and HCV serology were performed. Hazardous alcohol use was assessed using the AUDIT questionnaire. A conditional logistic regression model was used to measure odds ratio (OR) with their 95% confidence intervals (CI). A total of 160 cases and 320 controls were included. Cases were predominantly men (80.0%) with a median age of 47 years (IQR 38-57). Hazardous alcohol use (OR = 4.5 [CI 1.1-18.5]), HBV infection (OR = 62.5 [CI 20.5-190.7]) and HCV infection OR = 35.9 [CI 10.0-130.3]) were independently associated with HCC. Combining the effect of HBV infection and alcohol, HBV-infected hazardous drinkers had an OR = 149.8 (CI 13.5-1 667.0), HBV mono-infected had an OR = 57.4 (CI 18.8-175.3) (ref: HBV-negative). Aside the independent association of alcohol use and HBV and HCV infection with HCC, a synergic effect between alcohol use and HBV infection was identified. Timely screening and care of HBV infection and hazardous drinking might prevent a significant number of HCC in West Africa.

Prevalence of hepatitis B and delta according to HIV-type: a multi-country cross-sectional survey in West Africa.

BACKGROUND: In West Africa where HIV-1 and HIV-2 co-circulate, the co-infection with hepatitis B virus (HBV) and hepatitis Delta virus (HDV) is not well described. This study aimed at estimating the prevalence of HBV and HBV/HDV co-infection according to HIV types and risk factors for HBV infection among West African HIV-infected patients. METHOD: A cross-sectional survey was conducted within the IeDEA West Africa cohort from March to December 2012 in Côte d'Ivoire (three sites), Burkina Faso and Mali (one site each). All HIV-infected adult patients on antiretroviral therapy (ART) or not who attended one of the participating HIV clinics during the study period and agreed to participate were included. Blood samples were collected and re-tested for HIV type discrimination, HBV and HDV serology as well as HBV viral load. Logistic regression was used to identify risk factors for HBV infection. RESULTS: A total of 791 patients were included: 192 HIV-1, 447 HIV-2 and 152 HIV-1&2 dually reactive. At time of sampling, 555 (70.2%) were on ART and median CD4+ cell count was 472/mm3 (inter-quartile range [IQR]: IQR: 294-644). Sixty-seven (8.5%, 95% CI 6.6-10.6) patients were HBsAg positive without any difference according to HIV type (7.9% in HIV-1, 7.2% in HIV-1&2 dually reactive and 9.4% in HIV-2; p = 0.61). In multivariate logistic analysis, age ≤ 30 years old (adjusted odds ratio [aOR] 5.00, 95% CI 1.96-12.76), age between 31 and 49 years old (aOR 1.78, 95% CI 1.00-2.21) and male gender (aOR 2.15, 95% CI 1.25-3.69) were associated with HBsAg positivity. HBV DNA testing was performed in 36 patients with blood sample available (25 on ART) and 8 (22.2%) had detectable HBV DNA. Among the HBsAg-positive individuals, 14.9% (95% CI 7.4-25.7) were also positive for anti-HDV antibody without any difference according to HIV type (28.6% in HIV-1, 14.3% in HIV-2 and 0.0% in HIV-1&2 dually reactive; p = 0.15). CONCLUSION: HBV and HBV/HDV co-infection are common in West Africa, irrespective of HIV type. Therefore, screening for both viruses should be systematically performed to allow a better management of HIV-infected patients. Follow-up studies are necessary to determine the impact of these two viruses on HIV infection.

[Stigma and discrimination experienced by people living with HIV in Togo, in 2013]. / Discrimination et stigmatisation vécues par les personnes vivant avec le VIH au Togo en 2013.

BACKGROUND: Stigma and discrimination experienced by people living with HIV (PLWHA) prevent and delay access to prevention and treatment services. The aim of this study was to describe the patterns of stigma and discrimination experienced by PLWHA in Togo and to identify the associated factors. METHODS: A cross-sectional study was conducted in 2013 among PLWHA in Togo in order to collect data on stigma or discrimination experiences. Univariate and multivariate analyses were performed to identify associated factors. RESULTS: A total of 891 PLWHA were interviewed, including 848 (95.2%) receiving antiretroviral therapy. External stigma (37.9%) was the major form of stigmatization followed by internalized stigma (35.4%). The main features of external stigma were gossip (36.5%) and issues to access education (36.0%). Internalized stigma mainly consisted of a feeling of guilt (37.6%) and self-devaluation (36.0%). In univariate and multivariate analysis, female gender was significantly associated with stigma (aOR = 1.73, 95% CI [1.08-2.77]). Of the 891 PLWHA, 75 (8.4%) reported a violation of their rights. Finally 27 (4.1%) were discouraged from having children by a health professional because of their HIV status. CONCLUSION: Stigma affects more than one-third of PLWHA in Togo, more particularly females. It appears necessary to design new interventions and integrate psychosocial care in the management of PLWHA, in addition to antiretroviral therapy.

Oral health and HIV infection among female sex workers in Abidjan, Côte d'Ivoire.

BACKGROUND: Worldwide, female sex workers (FSW) represent a vulnerable population for oral diseases due to many risk factors including HIV infection and drug abuse. In sub-Saharan Africa, little is known about the burden of oral diseases and their determinants in vulnerable populations. The aim of the study was to estimate the prevalence and associated factors of oral diseases among FSW. METHODS: A cross sectional study was conducted among FSW who attended a dedicated non-profit clinic in Abidjan, Côte d'Ivoire from June to August 2013. Data about the presence of dental caries, periodontitis and oral-mucosal lesions were collected by a dentist during an oral examination. Behavioural information related to oral hygiene habits as well as tobacco and alcohol consumption were collected through a standardized questionnaire. Information related to HIV infection including HIV diagnosis, last known CD4 count and antiretroviral therapy were documented through a medical chart review. Logistic regression models were used to identify factors associated with oral diseases. RESULTS: A total of 249 FSW with a median age of 29 years, [Inter Quartile Range (IQR) = 23-36] and a median duration of sex work of 24 months [IQR 9-60]) were included. Current tobacco use and hazardous alcohol use were reported in 21.7 % and 19.7 % of FSW, respectively. The estimated prevalence of HIV infection was 33.7 % [95 % confidence interval (CI); 27.8 - 39.6]) and 82.1 % of HIV-infected FSW were on antiretroviral therapy . The prevalence of dental caries, periodontitis and oral-mucosal lesions were 62.3 % [95 % CI 55.5 - 67.5], 14.5 % [95 % CI 10.2 - 18.9] and 8.2 % [95 % CI 4.8 - 11.5], respectively. In multivariate analysis, periodontitis, oral-mucosal lesions and HIV infection were associated with odds ratio of 2.6 [95 % CI, 1.2-5.8]) and 50.0 [95 % CI; 6.4-384.6]. CONCLUSIONS: This study showed a high prevalence of oral diseases among FSW in Abidjan. HIV infection was common and significantly associated with periodontal diseases and oral-mucosal lesions. There is a need to integrate regular screening and treatment of oral lesions into the medical follow-up of FSW along with strategies for HIV prevention.

Antiretroviral therapy response among HIV-2 infected patients: a systematic review.

BACKGROUND: Few data are available on antiretroviral therapy (ART) response among HIV-2 infected patients. We conducted a systematic review on treatment outcomes among HIV-2 infected patients on ART, focusing on the immunological and virological responses in adults. METHODS: Data were extracted from articles that were selected after screening of PubMed/MEDLINE up to November 2012 and abstracts of the 1996-2012 international conferences. Observational cohorts, clinical trials and program reports were eligible as long as they reported data on ART response (clinical, immunological or virological) among HIV-2 infected patients. The determinants investigated included patients' demographic characteristics, CD4 cell count at baseline and ART received. RESULTS: Seventeen reports (involving 976 HIV-2 only and 454 HIV1&2 dually reactive patients) were included in the final review, and the analysis presented in this report are related to HIV-2 infected patients only. There was no randomized controlled trial and only two cohorts had enrolled more than 100 HIV-2 only infected patients. The median CD4 count at ART initiation was 165 cells/mm3, [IQR; 137-201] and the median age at ART initiation was 44 years (IQR: 42-48 years). Ten studies included 103 patients treated with three nucleoside reverse transcriptase inhibitors (NRTI). Protease inhibitor (PI) based regimens were reported by 16 studies. Before 2009, the most frequent PIs used were Nelfinavir and Indinavir, whereas it was Lopinavir/ritonavir thereafter. The immunological response at month-12 was reported in six studies and the mean CD4 cell count increase was +118 cells/µL (min-max: 45-200 cells/µL). CONCLUSION: Overall, clinical and immuno-virologic outcomes in HIV-2 infected individuals treated with ART are suboptimal. There is a need of randomized controlled trials to improve the management and outcomes of people living with HIV-2 infection.

Cervical cancer prevention in reproductive health services: knowledge, attitudes and practices of midwives in Côte d'Ivoire, West Africa.

BACKGROUND: Cervical cancer is the most common cancer among women and the leading cause of cancer deaths in women in Côte d'Ivoire. Low resource countries can now prevent this cancer by using HPV vaccine and effective and affordable screening tests. However the implementation of these prevention strategies needs well-trained human resources. Part of the solution could come from midwives by integrating cervical cancer prevention into reproductive health services. The aim of this survey was to assess knowledge, attitudes and practices of midwives towards cervical cancer prevention in Abidjan, Côte d'Ivoire, and to find out factors associated with appropriate knowledge. METHODS: A cross-sectional survey was conducted among midwives in the urban district of Abidjan, using a self-administered questionnaire. Knowledge was assessed by two scores. Factors associated with appropriate knowledge were determined using a logistic regression analysis. Attitudes and practices were described and compare using the Chi2 test. RESULTS: A total of 592 midwives were enrolled, including 24.5% of final-year students. 55.7% of midwives had appropriate knowledge on cervical cancer, and 42.4% of them had appropriate knowledge on cervical cancer prevention strategies. Conferences, courses taken at school of midwifery and special training sessions on cervical cancer (OR = 4.9, 95% CI [1.9 to 12.6], p <0.01) were associated with good knowledge on the management of this disease. Among these midwives, 18.4% had already benefited from a screening test for themselves, 37.7% had already advised screening to patients and 8.4% were able to perform a visual inspection. 50.3% of midwives knew HPV vaccine as a preventive method; among them 70.8% usually recommended it to young girls. CONCLUSION: Despite sufficient knowledge about cervical cancer prevention, attitudes and practices of midwives should be improved by organizing capacity building activities. This would ensure the success of integration of cervical cancer prevention into reproductive health services in countries like Côte d'Ivoire.

Uptake, Acceptability, and Results of SARS-CoV-2 Antigen Rapid Diagnostic Testing in Community Settings in Cameroon.

Mass gathering event restrictions were part of mitigation measures during the COVID-19 pandemic that were lifted as prevalence decreased and after vaccination rollout. We explored SARS-CoV-2 antigen rapid diagnostic test acceptability and positivity in community settings in Cameroon. In August-October 2022, community workers sensitized and referred individuals for COVID-19 testing to nearby testing points in Douala and Yaoundé. Participants consented to SARS-CoV-2 antigen rapid diagnostic testing, a survey, or both components. We describe the positivity rate, COVID-19-related history, and Likert-scale testing perceptions. Factors associated with testing acceptance were analyzed using logistic regression. Overall, 20.5% (2,449/11,945) of sensitized individuals visited testing points, and 1,864 (76.1%) were enrolled; 50.6% accepted the survey and testing (46.0% accepted survey only). Seven (0.7%) of 1,006 individuals tested positive. Most (71.8%; 1,292/1,800) considered community testing more accessible than hospital-based testing. Individuals accepting versus refusing testing differed in perceived COVID-19 risk (67%, 49%; P <0.001), belief in accurate test results (79%, 47%; P <0.001), and ability to test easily (96%, 55%; P <0.001). Males (adjusted odds ratio [aOR]: 1.26 [1.04-1.53]) and those over 50 years (aOR: 1.9 [1.4-2.7]), with symptoms (aOR: 1.80 [1.30-2.50]), and at least partial vaccination (aOR: 0.76 [0.58-0.99]) were significantly associated with test acceptance. Refusal reasons included lack of perceived need for testing (33.8%) and testing discomfort (26.3%). Although community-based testing was generally perceived as important, actual testing uptake was low. In future pandemics, community testing should be optimized by addressing misinformation, offering alternative testing modalities for greater comfort, creating demand, and tailoring approaches to maximize testing uptake.

Follow-Up Outcomes of Children, Adolescents, and Young People on Darunavir-Based Third-Line Antiretroviral Therapy: Observational Cohort From 9 African Countries.

BACKGROUND: We assessed clinical outcomes among children, adolescents, and people younger than 25 years on darunavir-based antiretroviral therapy (ART) in 9 sub-Saharan African countries. SETTING: Third-line ART centers in Cameroon, Eswatini, Kenya, Lesotho, Nigeria, Rwanda, Uganda, Zambia, and Zimbabwe. METHODS: From January 2019 to December 2022, we collected data from a cohort of children, adolescents, and young people receiving third-line ART from 9 sub-Saharan African countries. Data on treatment continuity, viral suppression, death, and clinic transfers were extracted from medical records and summarized. Cox proportional hazards models were used to identify factors independently associated with retention in care. RESULTS: Of 871 participants enrolled, the median age was 14.8 (range: 0.2-24.7) years and 488 (56.0%) were male; 809 (92.9%) [median duration of follow-up of 28.3 months (interquartile range: 17.5-45.2)] had final outcomes after initiating third-line ART. Of these, 711 (87.9%) were alive and in care at the end of study follow-up, 29 (3.6%) died, 30 (3.7%) were transferred to other facilities, and 39 (4.8%) were lost to follow-up. Retention in care was less likely among male patients compared with female patients [aHR: 0.85, 95% confidence interval: 0.72 to 1.0] and in 10-14-year-old children compared with younger children. Adolescents (15-19 years old) had higher mortality compared with children younger than 10 years (aSHR: 4.20, 95% confidence interval: 1.37 to 12.87). Viral suppression was seen in 345/433 (79.7%), 249/320 (77.8%), and 546/674 (81.0%) patients with results at 6 months, 12 months, and study end, respectively. CONCLUSIONS: A high proportion of children and young people receiving third-line ART in sub-Saharan Africa remain in care and attain viral suppression during follow-up.

Assessment of knowledge and self-efficacy among health professionals and clinical scientists following the Cameroon HIV/AIDS Research Forum (CAM-HERO 2022) research methodology and bioethics training.

To inform public health policymakers that the generation of local evidence-based knowledge is key. Research capacity in low- and middle-income countries (LMIC) to generate medical knowledge is often weak and insufficiently resourced and efforts to tackle these challenges are not standardized. Continuous research training can equip researchers with the required knowledge and research skills, but its effectiveness largely depends on the quality and pertinence of the training methods used. We aim to assess the effectiveness of the Cameroon HIV/AIDS Research Forum (CAM-HERO) 2022 Research Methodology and Bioethics Training with the objective to describe the knowledge gained and the self-efficacy of health professionals and clinical scientists. A survey was conducted during the one-day training among health professionals and clinical scientists. Participants took an online self-administered questionnaire before and after the training related to the topics taught. The questionnaire consisted of two parts: 1) 18 Multiple Choice Questions (MCQs) to assess knowledge and 2) Nine items to evaluate self-efficacy using a five-point Likert scale. Mean scores were calculated, analysed, and compared using paired t-test for the pre- and post-test results. A total of 30 participants (57% women) completed the socio-demographic form. The median age (IQR) of participants was 33.5 (13.3) years. We registered 38 respondents for the pre-test and 33 respondents for the post-test. There was a rise in knowledge mean score from 13.0 to 14.8 (p=0.001) and an improvement in the perception of self-efficacy with a mean score increase from 2.9 to 3.7 (p < 0.001). Knowledge and perception of self-efficacy on research methodology improved among participants after the training. These results suggest that the CAM-HERO 2022 training had an immediate positive impact on skills and self-efficacy. Hence, we recommend the implementation of this training on a larger scale, periodically, and with long-term follow-up to evaluate its impact.

Integration of HIV Testing in a Community Intervention for Tuberculosis Screening Among Household Contacts of Patients with Tuberculosis in Cameroon and Uganda.

INTRODUCTION: People living with HIV are considered at higher risk of developing severe forms of tuberculosis (TB) disease. Providing HIV testing to TB-exposed people is therefore critical. We present the results of integrating HIV testing into a community-based intervention for household TB contact management in Cameroon and Uganda. METHODS: Trained community health workers visited the households of index patients with TB identified in 3 urban/semiurban and 6 rural districts or subdistricts as part of a cluster-randomized trial and provided TB screening to all household contacts. Voluntary HIV counseling and testing were offered to contacts aged 5 years or older with unknown HIV status. We describe the cascade of care for HIV testing and the factors associated with the acceptance of HIV testing. RESULTS: Overall, 1983 household contacts aged 5 years or older were screened for TB. Of these contacts, 1652 (83.3%) did not know their HIV status, 1457 (88.2%) accepted HIV testing, and 1439 (98.8%) received testing. HIV testing acceptance was lower among adults than children [adjusted odds ratio (aOR) = 0.35, 95% confidence interval (CI): 0.22 to 0.55], those living in household of an HIV-positive vs HIV-negative index case (aOR = 0.56, 95% CI: 0.38 to 0.83), and contacts requiring a reassessment visit after the initial TB screening visit vs asymptomatic contacts (aOR = 0.20, 95% CI: 0.06 to 0.67) and was higher if living in Uganda vs Cameroon (aOR = 4.54, 95% CI: 1.17 to 17.62) or if another contact of the same index case was tested for HIV (aOR = 9.22, 95% CI: 5.25 to 16.18). CONCLUSION: HIV testing can be integrated into community-based household TB contact screening and is well-accepted.

Effect of COVID-19 on paediatric TB service delivery and patients' comfort receiving TB services in Cameroon and Kenya during COVID: a qualitative assessment.

BACKGROUND: The outbreak of COVID-19 has caused a setback to the gains achieved in tuberculosis (TB) control by impairing TB diagnosis, delaying treatment initiation and aggravating TB deaths. This study explored the effect of COVID-19 on paediatric TB services provided through the Catalysing Paediatric TB Innovations (CaP-TB) project among caregivers of children receiving TB services and healthcare workers (HCWs) providing TB services in Cameroon and Kenya. METHODS: From March to September 2021, in-depth interviews (44) were conducted with caregivers whose children under 5 years had gone through TB services and programme managers (10) overseeing the CaP-TB project. Focus group discussions were conducted with HCWs (07) and community health workers (04) supporting TB care services. Transcripts were coded and analysed by using MAXQDA V.12. RESULTS: The COVID-19 pandemic has caused fear and anxiety among HCWs and caregivers. This fear was motivated by stigma related to COVID-19 and affected the ability to screen patients for TB due to the similarity of symptoms with COVID-19. The health-seeking behaviour of patients was affected, as many caregivers avoided hospitals and those accessing the facilities concealed their sickness due to fear of testing positive or being vaccinated. In addition, COVID-19 mitigation strategies implemented by both government and health facilities to curb the spread of the virus limited patient access to paediatric healthcare services. These included temporary closure of health facilities due to COVID-19 infections among staff, transfer of services to other spaces, spacing out patient appointments and reduced time spent with patients. CONCLUSIONS: The outbreak of COVID-19 has induced fear and stigma that affected patients' health-seeking behaviour and provider attitudes towards paediatric TB service delivery. In addition, facility and governmental measures put in place to mitigate COVID-19 impact negatively affected paediatric service delivery. Training for health personnel, timely provision of personal protective equipments and appropriate communication strategies could help mitigate COVID-19 impact on paediatric TB service delivery.

Improving TB detection among children in routine clinical care through intensified case finding in facility-based child health entry points and decentralized management: A before-and-after study in Nine Sub-Saharan African Countries.

In 2022, an estimated 1.25 million children <15 years of age developed tuberculosis (TB) worldwide, but >50% remained undiagnosed or unreported. WHO recently recommended integrated and decentralized models of care as an approach to improve access to TB services for children, but evidence remains limited. The Catalyzing Paediatric TB Innovation project (CaP-TB) implemented a multi-pronged intervention to improve TB case finding in children in nine sub-Saharan African countries. The intervention introduced systematic TB screening in different facility-based child-health entry-points, decentralisation of TB diagnosis and management, improved sample collection with access to Xpert® MTB/RIF or MTB/RIF Ultra testing, and implementation of contact investigation. Pre-intervention records were compared with those during intervention to assess effect on paediatric TB cascade of care. The intervention screened 1 991 401 children <15 years of age for TB across 144 health care facilities. The monthly paediatric TB case detection rate increased significantly during intervention versus pre-intervention (+46.0%, 95% CI 36.2-55.8%; p<0.0001), with variability across countries. The increase was greater in the <5 years old compared to the 5-14 years old (+53.4%, 95% CI 35.2-71.9%; p<0.0001 versus +39.9%, 95% CI 27.6-52.2%; p<0.0001). Relative contribution of lower-tier facilities to total case detection rate increased from 37% (71.8/191.8) pre-intervention to 50% (139.9/280.2) during intervention. The majority (89.5%) of children with TB were identified through facility-based intensified case-finding and primarily accessed care through outpatient and inpatient departments. In this multi-country study implemented under real-life conditions, the implementation of integrated and decentralized interventions increased paediatric TB case detection. The increase was driven by lower-tier facilities that serve as the primary point of healthcare contact for most patients. The effect was greater in children < 5 years compared to 5-14 years old, representing an important achievement as the TB detection gap is higher in this subpopulation. (Study number NCT03948698).

Operational Research to Support Rapid Evidence-Based Responses to Outbreaks: Learnings from COVID-19.

During the COVID-19 pandemic, the need for making testing readily available was recognized as an important factor for individuals to help make informed decisions, including to isolate or seek care, and for policymakers to control transmission. Toward this end, FIND and the Access to COVID-19 Tools Accelerator funded 16 rapid operational research studies and one implementation project in Africa, the Caribbean, and Asia evaluating the utility, acceptability, and feasibility of different community-based SARS-CoV-2 testing approaches. Here, we discuss common factors and challenges encountered during study implementation. We note six key factors essential for success: 1) collaboration and partnerships; 2) buy-in of local stakeholders, including communities; 3) access to affordable supplies; 4) flexible financing; 5) effective approval systems; and 6) a skilled and motivated workforce. We also note various challenges that must be addressed to fully capitalize on these success factors. In particular, ethics committees are often not well equipped to assess operational research during outbreaks. Outbreaks, especially of novel pathogens, are unpredictable, and transmission dynamics are even more likely to change if the pathogen is prone to frequent mutations, such as SARS-CoV-2. Research that aims to evaluate strategies for curbing transmission must hence be easily and swiftly adaptable. This requires flexibility from researchers, funders, staff conducting the studies, and ethics and other approval committees. International guidelines for evaluating operational research protocols in outbreaks are needed to provide timely evidence to enable informed decisions by individuals, communities, and policymakers, thereby reducing both the human and the economic impact of outbreaks.

Improving COVID-19 contact tracing and testing of exposed individuals in Cameroon using digital health technology: a cluster randomised trial.

Background: Contact tracing was described as a key strategy to contribute to controlling the spread of severe acute respiratory syndrome of Coronavirus 2 (SARS-CoV-2) but implementing it can be a challenge. Digitalisation of contact tracing is among the proposed solutions being explored in sub-Saharan African settings. We assessed the effectiveness of a digital tool to expand SARS-CoV-2 testing in exposed individuals in Cameroon. Methods: We conducted a cluster-randomised (1:1) trial in eight health districts, including 22 facilities and SARS-CoV-2 testing units, randomly assigned to a digital (intervention) or standard (control) contact tracing approach. The intervention consisted of a contact tracing module added to the digital platform "Mamal PRO" used for monitoring and coordination of Coronavirus Disease 2019 pandemic response in Cameroon. The primary outcome was the proportion of contacts declared by SAR-CoV-2 index patients who were successfully traced and tested for SARS-CoV-2 evaluated with a Poisson regression model with cluster adjustment. This study is registered with ClinicalTrials.gov (NCT05684887). Findings: Between October 18, 2022, and March 31, 2023, we enrolled 164 index patients in the intervention arm and 149 in the control arm, who identified 854 and 849 contacts, respectively. In the intervention arm, 93.8% (801/854) of identified contacts were successfully reached by the tracing unit versus 54.5% (463/849) in the control arm. The intervention significantly increased the likelihood of successfully tracing contacts (adjusted relative risks (RR) 1.72 [95% CI: 1.00-2.95], p = 0.049). The median (interquartile range, IQR) time to successfully tracing contacts was 0 days [IQR: 0, 1] in the intervention and 1 day [IQR: 0, 2] in the control arm. In the intervention arm, 21.3% (182/854) of identified contacts received SARS-CoV-2 testing compared to 14.5% (123/849) in the control arm (adjusted RR 1.47 [95% CI: 0.44-4.90], p = 0.530). Interpretation: Digitalising the contact tracing process improved exposure notification and facilitated the tracing of a greater number of contacts of individuals infected with SARS-CoV-2 in resource-limited settings. Funding: The study was funded by FIND, United Kingdom (FCDO 40105983), Switzerland (81066910), Netherlands (SDD 4000004160), Canada (DFATD 7429348), The Kingdom of Saudi Arabia (FIND-ACT-A DX PARTNERSHIP 20.08.2020), The Rockefeller Foundation (2020 HTH 059), Germany (BMZ Covid-19 Diagnostic and Surveillance Response 27.07.2021), Australia (DFAT 76442), Kuwait (M239/2020), The Government of Portugal and Partners (ANF, BCP, CGF, APIFARMA) and The BlackRock Foundation (Grant Agreement as of April 20, 2022).